RU2778776C1 - Plate for stabilising the chest in children and method for application thereof for treating rigid forms of pectus carinatum - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: group of inventions relates to medicine, namely, to traumatology and orthopaedics, and can be used for treating pectus carinatum in children. Plate for stabilising the chest in children comprises an elastic element with transverse rib fasteners installed at the ends, consisting of two overlapped parts screwed on the elastic element. Parts of a fastener are made of curved Z-shaped plates and are connected in reverse direction. The lower, horizontal sides of the fastener therein act as supports. The length of the upper enveloped horizontal part is equal to the width of the elastic element, the end section of the upper horizontal enveloping part is folded congruently to the contour of the vertical side of the enveloped part. Coaxial holes for a captive screw are made at the centre of the upper horizontal parts. The anterior sternal wall is mobilised from both sides transversely, in the intercostal area of the 6-8 intercostal spaces, from the incision at the apex of chest deformation, as well as the parasternal parts of 8-10 costal cartilages. Oblique corticotomy of the sternum is performed at the top of the deformation, incomplete oblique chondrotomy of the isolated cartilaginous parts of the ribs is performed. Subperiosteal isolation of the upper and lower rib edges is performed from the incisions in the projection of the 6 intercostal space. The ends of the plate are secured to the ribs using fasteners.

EFFECT: group of inventions reduces the trauma rate and increases the effectiveness of surgical treatment by eliminating the deformation of the sternocostal complex without violating the biomechanical integrity thereof and by ensuring stable fixation thereof in a corrected position.

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Description

SUBSTANCE: group of inventions relates to medicine, namely to traumatology and orthopedics, and is intended for the treatment of keeled deformity of the chest and other malformations of the anterior chest wall.

1. Keeled deformity of the chest (KDHK) is a malformation that manifests itself in a different shape and size, protrusion of the anterior wall of the chest. KDHK, according to various authors, is from 6 to 22% of all congenital deformities of the chest, the latter occur in about 1% of people, and are usually treated surgically. Indications for surgical treatment are III-IV degree deformities, progression of deformity, psychological discomfort, impaired movement of the chest during inspiration, compression or displacement of the heart according to CT, echocardiography, compressed lungs according to CT, impaired lung parameters according to spirography, etc. .

From the method according to the patent of the Russian Federation No. 2373878, A61BB 17/56, bul. No. 33, 2009, a metal plate is known, made in the form of a springy arc, which is used to eliminate the keeled deformity of the chest. The plate is installed in front of the sternum at the level of the greatest protrusion of the sternocostal hump, in the subcutaneous tunnel formed through the contra-aperture accesses along the lateral surfaces of the chest. After simultaneous compression of the sternum and immobilization of the sternocostal complex, the ends of the plate are fixed to the ribs with a wire. However, fixing with wire by the ribs on both sides of the ends of the metal plate in the form of a spring-loaded arc is not sufficient to hold this plate in the position of the HRC correction, especially in cases of rigid deformities. Given the significant period of wearing the implant (1 year), and the constant excursion of the chest, due to the high tension in the contact area, it is possible to cut the rib with a wire loop. In addition, there are difficulties in operational technology and technology, leading the wire by the ribs, creating a degree of tension in the wire loop when attached to the plate, which does not exclude the rupture of the wire when it is twisted. Traction for one rib does not provide sufficient correction and volume of the chest throughout the deformity.

Known plate for stabilizing the deformation of the chest according to the patent of the Russian Federation No. 160899 A61V 17/80, Bull. No. 22, 03/14/2016 This device consists of an elastic element and transverse plates. In the center of each transverse plate, on one of its sides, there is a cylindrical protrusion equipped with an internal thread. Around the protrusion, radially, at the same distance from the center, and at an equal distance from each other, at least four teeth are placed. At the ends of the elastic element, along the axis, through holes are made, in response to the protrusions on the said plates. Teeth are made around the holes, corresponding to the teeth of the transverse plates, the plates are fixed on the elastic element with screws. However, when installing and removing the transverse plates along the back surface of the ribs, technical difficulties arise: due to the fact that this element of the device is non-separable, the time for mounting and removing the structure is lengthened, in addition, these manipulations can lead to damage to the intercostal nerves.

The closest design to our proposed technical solution is a plate for stabilizing the deformation of the chest according to patent No. 2741235, A61B 17/80, Bull. No. 3, 2020 This plate contains an elastic element with detachable transverse plates fixed at the ends, each of which consists of two parts. Parts of the plate are overlapped with each other and have transverse teeth of a reciprocal shape on adjacent surfaces. Along the longitudinal axis of the lower part of each transverse plate, in the area of the said teeth, a hexagonal rod with an internal threaded hole along the axis is vertically installed. On the upper part of the plates, also along the longitudinal axis, in the region of the teeth, an open longitudinal groove is made, the width of which corresponds to the outer size of the hexagonal rod mounted on the lower part. The end sections of the parts of the transverse plates are bent upwards. At the ends of the elastic element, hexagonal through holes are made corresponding to the dimensions of the hexagonal rods on the transverse plates. However, the installation of transverse plates in the depth of the wound is difficult, there is no fixation relative to each other, and since the elastic plate is superimposed on top of the rib, and a distance equal to the thickness of the rib remains between the upper transverse plate and the fixed elastic plate, such an installation creates instability due to the movement of the plates relative to each other on a hexagonal rod.

The purpose of the invention is to simplify the technology of installation and removal of the chest stabilization plate by minimally invasive surgery.

The essence of the task lies in the totality of essential features sufficient to achieve the desired technical result, which consists in creating a structure that ensures its installation and removal, in conditions of limited operational access, while reducing the time of surgical intervention.

The essence of the invention lies in the fact that the plate for stabilizing the chest in children and adolescents contains an elastic element with transverse rib clamps installed at the ends, consisting of two parts, which are overlapped with each other and fixed to the elastic element with a screw. Parts of the latch are made of curved Z-shaped plates, and are connected in opposite directions, one of which is a male part, the other is a female part. In this case, the lower, horizontal, sides of the latch are supports, the length of the supports of both parts of the latch is equal to the width of the ribs. The length of the upper, male, horizontal part is equal to the width of the elastic element, the end section of the upper horizontal female part is bent congruently to the contour of the vertical side of the male part, while the height of the male, inner part of the latch is equal to the sum of the heights of the rib and the elastic element. In the center of the upper horizontal parts, coaxial holes for the captive screw are made, and in the male, upper, horizontal part, the hole is threaded, and the length of the smooth part of the screw shaft exceeds the sum of the thicknesses of the upper horizontal parts of the latch.

The execution of the retainer parts from Z-shaped plates (Fig. 1, Fig. 2, Fig. 3) allows, from a small incision, with little tissue mobilization, to carry out the supporting lower horizontal parts of the Z-shaped plates along the back surface of the rib with the removal of their upper horizontal part to the level of the front surface of the rib. The male plate is installed first, its opposite connection, with the imposition of the female part of the latch, with the end bent downwards, on the male, horizontal part, which makes it possible to prevent displacement of the plate parts, both in the horizontal and vertical planes.

The support of the Z-shaped plates of both parts of the latch with a length equal to the width of the ribs ensures their contact on the wide plane of the rib, which prevents rib eruption during the correction of the HRC by the action of an elastic plate, and distraction (traction) of the corrected deformity of the chest.

The execution of the upper, and covered, horizontal, part with a length equal to the width of the elastic plate, ensures the holding, and installation, of the elastic plate in the latch.

Making the length of the female upper horizontal plate greater than the length of the male one, and bending its end downwards, congruent to the contour of the vertical side of the male part, ensures stable fixation of the Z-shaped plates relative to each other in the horizontal and vertical planes after the installation of the elastic plate and fixing it with a screw.

The implementation of the height of the covered, internal, part of the latch, equal to the sum of the heights of the rib and the elastic plate, ensures the fixation of the elastic plate at the level of the upper plane of the costal arch

Coaxial holes in the center of the upper horizontal parts for the screw, with threading in the male, upper, horizontal part, allows you to connect the parts of the latch to each other before installing the elastic plate, which ensures the unity and rigidity of the latch design. The use of a captive screw with the length of the smooth part of the rod exceeding the sum of the thicknesses of the upper horizontal parts of the retainer makes it possible to create a reliable connection of the retainer parts after they are superimposed on each other, and after installing the ends of the plate into the retainers, with further screwing in of the screw, connect the retainers and the plate.

The chest stabilization plate consists of an elastic element 1 and transverse rib clamps installed at its ends, each of which consists of two parts 2 and 3, overlapped with each other with a screw 4. Each part 2 and 3 of the clamp is made of Z-shaped plates. The parts of the latch are connected to each other in the opposite direction, while part 2 is male, part 3 is female. The length of the lower supports 5 of both parts of the latch 2 and 3 is equal to the width of the ribs. The length of the upper, horizontal, male part 6 is equal to the width of the elastic element 1, and the length of the upper, horizontal, female part 7 is greater than the length of the male part 6, and is bent at the end, congruent to the contour of the vertical side of the male part 2. The height of the male, internal, part of the latch 2 is equal to the sum of the heights of the rib and the elastic plate 1. In the center of the upper, horizontal parts 6 and 7, coaxial holes 8 and 9 are made for the screw 4, and the hole 8 in the female part 7 is through, and in the male part 6 there is a threaded hole 9.

2. A method for treating congenital keeled chest deformity in children and adolescents using a chest stabilization plate refers to medicine, namely, orthopedics, and is intended for the treatment of keeled chest deformity.

Keeled deformity of the chest (CDCC) is a malformation that manifests itself in a protrusion of the anterior wall of the chest of various shapes and sizes. KDHK, according to various authors, is from 6 to 22% of all congenital deformities of the chest, the latter occur in about 1% of people, and are usually treated surgically. Indications for surgical treatment are H1-IV degree deformities, progression of deformity, psychological discomfort, impaired movement of the chest during inspiration, compression or displacement of the heart according to CT, echocardiography, compression of the lungs according to CT, violations of lung parameters according to spirography, etc.

A known method of thoracoplasty keeled deformity of the chest, described in Ed. Certificate USSR No. 963512 А61В 17/00 Bull. No. 37, 1982, consisting in the separation of the pectoral muscles from the sternum and ribs, osteotomy of the xiphoid process with rectus abdominis muscles, wedge-shaped osteotomy of the sternum at the level of 1-11 intercostal spaces, and its longitudinal resection, 0.5 cm away from the place of attachment of the ribs, followed by the intersection of the II-VII ribs on both sides at the point of transition of the cartilaginous part to the bone. After these manipulations, the transected ribs are transposed along with the remaining bone plates of the sternum body to the center, the resected edges of the sternum are combined with the ribs, and sutured with lavsan threads, with the 11th rib attached to the handle of the sternum. The xiphoid process with the rectus abdominis and pectoral muscles are sutured to the remains of the sternum.

A significant disadvantage of this method of treatment of CDGK is the great trauma of the operation associated with total, or subtotal, resection of a part of the sternum and costal cartilages. Since the main point in the development of chest deformity is genetically determined costal cartilage dysplasia, the deformity of the sternum is secondary. Therefore, there is no need to conduct operations with KDGK in such a volume. Prevention of deformity recurrence during the child's growth period should be aimed at correcting the deformity of the sternocostal complex (SRC), long-term fixation in the withdrawn position until the formation of an anatomic costocartilaginous structure.

A known method for the treatment of congenital keeled deformity of the chest in children according to the patent of the Russian Federation No. 2373878, A61BB 17/56, Bull. No. 33, 2009, taken by us as a prototype. In this method, a transverse sternotomy is performed at the base of the curvature of the sternum. At the level of the greatest protrusion of the sternocostal hump, on the lateral surfaces of the chest, counter-aperture accesses are applied, through which a subcutaneous tunnel is formed towards each other. A metal plate made in the form of a springy arc is placed in the tunnels, after which simultaneous compression of the sternum and immobilization of the sternocostal complex are carried out, with the ends of the plate fixed to the ribs.

This method does not completely eliminate the longitudinal deformation of the sternum. Fixation of the achieved simultaneous correction of the keeled deformity of the chest by suturing the ribs to the plate is traumatic, may be accompanied by compression of the intercostal nerves, blood vessels, does not allow the rib cage to be held in the corrected position due to the failure of the sutures, eruption of the wire sutures, a long period of fixation is required for the transformation of the costal-cartilaginous structures

The essence of the invention consists in a set of essential features sufficient to achieve the desired technical result, which consists in reducing the trauma of surgical treatment of keeled chest deformity, while increasing its effectiveness by eliminating the deformation of the sternocostal complex without violating its biomechanical integrity, ensuring stable fixation in a corrected position , with the achievement of a cosmetic effect in a shorter fixation period.

The essence of the method of surgical treatment of rigid forms of keeled chest deformity in children includes the violation of the integrity of the sternocostal complex, the implementation of counter-aperture approaches, simultaneous compression of the sternum and immobilization of the sternocostal complex by fixing the ends of the plate to the ribs. Longitudinal incision lines are marked in the projection of the middle of the sternum, and on both sides transversely, in the region of the intercostal space of 6-8 intercostal spaces, from the incision at the top of the chest deformity, the anterior wall of the sternum, parasternal parts of 8-10 costal cartilages are mobilized. An oblique corticotomy of the sternum is performed at the top of its deformity, an incomplete oblique chondrotomy of the selected cartilaginous parts of the ribs. From the incisions in the projection of the 6th intercostal space, which is determined by the level of the apex of the keeled deformity of the chest, subperiosteal isolation of the upper and lower edges of the ribs is performed. Fixing the ends of the plate for stabilizing the chest according to claim 1. to the ribs is carried out with the help of transverse clamps made of curved plates having a Z-shape, consisting of two parts connected to each other counter and overlap. From the incisions in the projection of the 6th intercostal space, which is determined by the level of the apex of the keeled chest deformity, the subperiosteal isolation of the upper and lower ribs is performed for 1.5-2 cm: the upper rib - from the lower side, and the lower rib - from the upper side. Z-shaped retainer plates are installed: the lower support of the male plate is inserted behind the rib, and the lower support of the female plate is similarly installed along the rear surface of the adjacent rib. The upper horizontal parts of the plates are connected by superimposing one part on another, aligning the holes, and installing a screw in them. A similar surgical manipulation is performed on the other side of the chest. The prepared elastic element is passed through a tunnel formed in soft tissues along the anterior surface of the sternum, its end is fixed in one of the installed rib clamps. One-stage correction of keeled chest deformity is performed by pressing on its apex, with fixing the second, opposite, end of the elastic plate in the prepared rib clamp on the opposite side of the chest. By screwing said screw into the elastic plate, it is connected to the installed rib clamps.

In rigid forms of CDGC, an intervention is performed on the sternum and parasternal cartilaginous part of 6-8 ribs on both sides by isolation, and oblique corticotomy of the sternum, and incomplete oblique chondrotomy of the ribs, followed by one-stage correction, and stable fixation with an elastic plate in detachable rib clamps Z-shaped forms mounted on opposite sides of the sternum.

Longitudinal oblique corticotomy of the sternum and incomplete chondrotomy of the ribs makes it possible to eliminate the rigidity of the FDC, ensure its mobility, and, importantly, maintain continuity with contact at the site of violation of the integrity of the elements of the sternocostal frame, and this creates conditions for an earlier restoration of its anatomical structure.

The use of detachable clamps made of curved plates having a Z-shape and connected in opposite directions for fixing the ends of the elastic plate to the ribs provides convenience and speed of their installation, reduces the operation time. The counter connection of the plates, with the imposition of the upper, female part, with the end bent downwards, on the male part, ensures the unity of the latch design, the strength of its connection, and the wide contact of the supporting lower horizontal parts of the Z-shaped plates with the ribs prevents damage to the latter

The device and method of its application are explained by the illustrations.

On FIG. 1 shows a female Z-shaped plate 3, where: 5 - lower support; 7 - upper, horizontal, part with a downward bend, 8 - screw hole;

On FIG. 2 - male Z-shaped plate 2, where: 5 - lower support; 6 - upper, horizontal part; 9 - threaded hole for the screw;

On FIG. 3 is a general view of the device for stabilizing the chest, consisting of an elastic plate 1, and transverse clamps made of curved plates having a Z-shape, where: 2 is a male Z-shaped plate; 3 - female Z-shaped plate; 4 - screw; 5 - lower supports of the female and male Z-shaped plates; 6 - upper, horizontal, covering part of the plate 3; 7 - upper, female, horizontal part of the plate with a bend downwards; 8 - screw hole.

On FIG. 4 - Fig. 6 shows a photo of the patient M-va, 15 years old (see clinical example), where:

On FIG. 4, Fig. 4-a - before surgery;

On FIG. 5, Fig. 5-a - 4 days after the operation;

On FIG. 6 - 6 months after the removal of the structure.

The chest stabilization plate is used to correct rigid forms of keeled chest deformity in children as follows.

With rigid forms of keeled chest deformity, using a felt-tip pen, mark the incision lines at the top of the deformity longitudinally in the projection of the middle of the sternum, and on both sides, transversely, in the intercostal space of 6-8 intercostal spaces. From the incision at the top of the deformity of the chest, the anterior wall of the sternum, parasternal parts of 8-10 costal cartilages are mobilized. An oblique corticotomy of the sternum is performed at the top of its deformation, an oblique chondrotomy of the selected cartilaginous parts of the ribs. From the incisions in the projection of the 6th intercostal space, which are determined by the level of the apex of the keeled deformity of the chest, subperiosteal isolation of the upper and lower edges of the ribs is performed for 1.5-2 cm: the upper rib - from the lower side, and the lower rib - from the upper side . The Z-shaped plates are installed: first, the male plate is installed by introducing its lower horizontal support part behind the rib. Similarly, the horizontal support part of the female plate is installed along the rear surface of the adjacent rib. The upper horizontal parts of the plates are connected by laying them one on top of the other, aligning the holes, and installing a screw in them. A similar surgical manipulation is performed on the other side of the chest. The prepared elastic element is passed through a tunnel formed in soft tissues along the anterior surface of the sternum, its end is fixed in one of the installed rib clamps. One-stage correction of keeled chest deformity is performed by pressing on its apex, with fixing the second, opposite, end of the elastic plate in the prepared rib clamp on the opposite side of the chest. By screwing said screw into the elastic plate, it is connected to the installed rib clamps.

Wounds are sutured in layers. The patient begins to walk independently 2-3 days after surgery. The stitches are removed after 2 weeks. The plate with rib clamps is removed 8-12 months after surgery.

Clinical example. Patient M-s, 15 years old, on April 2, 2018, was admitted to the pediatric traumatological and orthopedic department of the Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan with a diagnosis of keeled deformity of the chest, corporocostal type, rigid form (Fig. 4, Fig. 4-a). On April 5, 2018, a surgical intervention was performed: Corticotomy of the sternum, partial parasternal 2-sided oblique chondrotomy of 6-8 ribs with the imposition of an elastic plate with rib clamps. Using a felt-tip pen at the top of the deformity, the incision lines were marked longitudinally in the projection of the middle of the sternum, and on both sides, transversely, in the region of the intercostal space of 6 intercostal spaces. From the incision at the top of the deformity of the chest, the anterior wall of the sternum was mobilized, the parasternal part of the 8-10 costal cartilages. Produced oblique corticotomy of the sternum at the top of its deformity, oblique, incomplete chondrotomy isolated cartilaginous parts of the ribs. From the incisions in the projection of the 6th intercostal space, along the anterior axillary line, subperiosteal isolation of the upper and lower edges of the ribs was made for 1.5: the upper rib - from the lower side, and the lower rib - from the upper side. The Z-shaped plates were installed: first, the male plate was installed by introducing its lower horizontal support part behind the lower rib. Similarly, the horizontal support part of the female plate was installed along the rear surface of the adjacent rib. The upper horizontal parts of the plates were connected by laying them one on top of the other, aligning the holes, and installing a screw in them. A similar surgical manipulation was performed on the other side of the chest. The prepared elastic element was passed through a tunnel formed in the soft tissues along the anterior surface of the sternum, its end was fixed in the left costal retainer. Made a one-time correction of the keeled deformity of the chest by pressing on its top, with fixing the second, opposite, end of the elastic plate in the prepared rib clamp on the right side of the chest. The said screw was screwed into the elastic plate, connecting it with the rib clamps.

On the 4th day the patient is activated (Fig. 5, Fig. 5-a). On the 6th day the patient was discharged for outpatient treatment. On March 5, 2019, the elastic plate, together with the rib clamps, was removed. 6 months after the removal of the structure: the shape of the chest has a normal configuration, there are no complaints (Fig. 6).

Claims (2)

1. A plate for stabilizing the chest in children, containing an elastic element with transverse rib clamps installed at the ends, consisting of two parts that are overlapped and fixed to the elastic element with a screw, characterized in that the parts of the latch are made of curved plates, have a Z-shape, and are connected in opposite directions, one of which is a male part, the other is a female part, while the lower horizontal sides of the latch are supports, the length of the supports of both parts of the latch is equal to the width of the ribs, the length of the upper, male, horizontal part is equal to the width of the elastic element, the end section of the upper horizontal female part is bent congruently to the contour of the vertical side of the male part, while the height of the male inner part of the latch is equal to the sum of the heights of the rib and the elastic element, coaxial holes for the captive screw are made in the center of the upper horizontal parts, and in the upper, covered, horizon The hole in the tal part is threaded, and the length of the smooth part of the screw shaft exceeds the sum of the thicknesses of the upper horizontal parts of the latch. 2. A method of surgical treatment of rigid forms of keeled chest deformity, including violation of the integrity of the sternocostal complex, performing counteraperture accesses, performing simultaneous compression of the sternum, and immobilizing the sternocostal complex by fixing the ends of the plate to the ribs, characterized in that longitudinal incision lines are marked in the projection of the middle of the sternum and on both sides, transversely, in the region of the intercostal space of 6-8 intercostal spaces, from the incision at the top of the deformity of the chest, the anterior wall of the sternum is mobilized, the parasternal parts of 8-10 costal cartilages, an oblique corticotomy of the sternum is performed at the top of its deformity, oblique chondrotomy of the selected cartilaginous parts of the ribs, from the incisions in the projection of the 6th intercostal space, which is determined by the level of the top of the keeled deformity of the chest, subperiosteal isolation of the upper and lower edges of the ribs is performed, fixing the ends of the plate to stabilize the chest according to claim 1 to the child frames are performed with the help of clamps made of curved plates having a Z-shape and connected in opposite directions, for which purpose, from the incisions in the projection 6 of the intercostal space, subperiosteal selection of the upper and lower ribs is performed for 1.5-2 cm: the upper rib - with the lower side, and the lower rib - from the upper side, and the Z-shaped plates of the clamps are installed: the lower support of the male plate is inserted behind the rib, the lower support of the female plate is similarly installed along the rear surface of the adjacent rib, the upper horizontal parts of the plates are connected by applying one part to another, with the holes aligned and the screw installed in them, a similar operational manipulation is performed on the other side of the chest, the prepared elastic element is passed through the tunnel formed in the soft tissues along the anterior surface of the sternum, its end is fixed in one of the installed rib clamps, one-stage keeled d correction deformation of the chest by pressing on its top, with fixing the second, opposite, end of the elastic plate in the prepared rib clamp on the opposite side of the chest, by screwing the said screw into the elastic plate, it is connected to the installed rib clamps.

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